| NPI | 1346276516 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: MT 11311) |
| Additional Taxonomies | 208600000X Surgery (Licence: AZ 3102) |
| 208600000X Surgery (Licence: WA OP00001682) | |
| 208600000X Surgery (Licence: ID O-0417) | |
| Enumeration Date | 2006-06-23 |
| Last Update Date | 2015-06-26 |